was it caring? did it make a difference? the couples miscarriage healing project
TRANSCRIPT
Was it caring? Was it caring? Did it make a difference?Did it make a difference?
The Couples The Couples Miscarriage Healing Miscarriage Healing
ProjectProject
Couples Miscarriage Healing Project
Kristen M. Swanson, RN, PhD, FAANAnthippy Petras, MSW
Hsien-Tzu Chen, RN, PhDDanuta Wojnar, RN, PhDRosalie Houston, RN, MN
Susan Sandblom, ARNP, MNJeannette Quaeck, RN, MN
Appalachia Martine, RN, BSNHelga Fridjonsdottir, RN, PhD
Alyson Shapiro, PhDChristopher Graham, PhD
During the first year after miscarriage, when couples engage in mutual sharing about their loss women report their interpersonal and sexual relationships become closer than before the miscarriage. (Swanson, 2003)
1 out of 6 pregnancies end in miscarriage
To compare the effects of nurse caring, self-caring, combined caring, and control (no intervention) on the emotional healing, integration of loss, and couple well-being of women and their male mates during the first year after miscarrying.
Couples Miscarriage Healing Project
Overall Purpose:
Non-probability sampling
• health care providers
• print & radio ads
• posters
• www, word of mouth
• participant referral
Enrollment Criteria
1. unplanned, unexpected, loss of pregnancy2. < 20 wks gestation at loss3. no more than 12 weeks since loss4. heterosexual couples5. if married, any age6. if in committed relationship, both 18 or older7. both partners willing to participate8. able to communicate in English (written and spoken)9. geographically accessible
• 341 Couples enrolled • up to 12 weeks post loss (M = 4.5 + 3.3 wks)
• Gestational age (M = 9.8 + 3.1 wks).
• Maternal age (M = 32.4 + 6.0 yrs)
• Paternal age (M = 33.9 + 6.7 yrs )
• 85% Caucasian, ~ 90% some college
Sample
Randomized Experimental Design
Phonescreen
randomized
nurse
self
combined
control
t2 t3t4
1 5 11 weeks
t1
weeks 6 16 52
X X X
X X X
X X X
0 Baseline
1.1. To describe the extent to which the nurse counseling sessions were perceived as caring by couples.
2. To describe how women and men felt about their miscarriage right after participating in counseling sessions.
Two goals for this presentation:Two goals for this presentation:
Nurse Caring Nurse Caring
Nurse counseling sessions with 84couples in their homes at
1 week5 weeks 11 weeks
Intervention FrameworkIntervention Framework
Process: Caring TheoryProcess: Caring Theory
Content: Miscarriage ModelContent: Miscarriage Model
(Swanson, 1983, 1986, 1991, 1993, 1999a, 1999b)
KnowingKnowing Doing for Doing for
Kristen M. Swanson, RN, PhD, FAAN
Being with:Being with: being emotionally present to being emotionally present to the other.the other.Knowing:Knowing: striving to understand an event as striving to understand an event as
it has meaning in the life of the other.it has meaning in the life of the other.
Doing forDoing for: doing for others as they would do doing for others as they would do for themselves if were at all possible.for themselves if were at all possible.
Enabling:Enabling: facilitating the other’s passage facilitating the other’s passage through events or transition by providing through events or transition by providing support, information, and validation.support, information, and validation.
Maintaining belief:Maintaining belief: sustaining faith in the sustaining faith in the other’s capacity to come through events other’s capacity to come through events or transitions and face a future with or transitions and face a future with
meaning.meaning.Recipient’s
feeling
EnablingEnablingBeing withBeing with
Maintaining beliefCARINGCARING
healinghealing
valuedvalued
understoodunderstood
safe and safe and comfortedcomforted
capablecapable
healingunderstoodunderstoodvaluedvaluedsafe and safe and comfortedcomfortedcapablecapablehopefulhopeful
Caring is a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility.
Swanson Caring TheorySwanson Caring Theory
Miscarriage Model
SESSION 1 – 1 weekComing to know – confusing painful process of balancing mounting evidence of impending loss against hopes for a healthy pregnancy outcome
Losing and Gaining – identifying what was lost and / or gained through miscarriage
SESSION 2 – 6 weeksSharing the loss – determining just who is and not available to share in and validate the loss
Going Public – facing the fertile world as a no longer expectant parent
SESSION 3 – 11 weeksGetting Through It – identifying when the good times in the day begin to outweigh the bad
Trying Again – making plans to conceive again while dealing with the ongoing fears of future loss
• If caring is what we claimed we delivered, what would couples say they received?
• Right after receiving counseling, how did women and men feel about their miscarriage?
QuestionsQuestions:
• Quantitative data: Paired T-tests Repeated Measures MANOVA
• Qualitative data: Content analysis
Methods:Methods:
• Barrett-Lenard Relationship Inventory: Empathy subscale only
• Swanson Caring Professional Scale: Compassionate Healer
Competent Practitioner
Measures:Measures:
PositiveInformativeClinically competent An attentive listenerCentered on youTechnically skilledRespectful of you
ComfortingUnderstandingPersonalCaringSupportiveAware of your feelingsVisibly touched by your experienceAble to offer you hope
Competent Practitioner
Compassionate Healer
Was the nurse who took care of you?
Session 1 Session 2 Session 3 Mean N Std. sig Mean N Std. sig Mean N Std. sig Caring Total W 71.36 83 4.498 .954 70.11 38 7.274 .087 70.08 36 6.465 .380 (possible range 18 – 75) M 71.40 83 4.997 71.84 38 4.110 70.94 36 5.466 Compassionate Healer W 38.06 84 2.748 .842 37.49 39 4.248 .141 37.56 36 4.252 .280 (possible range 8 – 40) M 38.13 84 2.583 38.46 39 2.584 38.31 36 2.528 Competent Practitioner W 33.55 78 2.111 .715 33.23 35 2.658 .462 32.91 35 2.418 .832 (possible range 7 – 35) M 33.65 78 2.094 33.51 35 2.092 32.80 35 3.008 Empathy W 52.23 84 5.893 .272 51.08 38 7.057 .740 53.19 37 5.778 .142 (possible range 10 – 60) M 51.50 84 4.988 51.39 38 5.989 51.62 37 6.452
No differences
Were there within couple differences in nurse ratings?
Was there a difference over time in how couples rated the nurses as caring, compassionate, competent, or empathetic?
Repeated measures MANOVA: Gender (2) X Nurse (2) X Time (3)
1. No differences in empathy based on time, gender, or nurse.
2. No differences in caring, competence, or compassion based on gender or nurse.
3.3. There were, however, differences in caring, There were, however, differences in caring, compassion, and competence over time.compassion, and competence over time.
Nurse Caring over three sessions
70.4
70.6
70.8
71
71.2
71.4
71.6
71.8
72
72.2
1 2 3
Counseling Session
Caring
time (p = .009)
Nurse Compassion and Competence over three sessions
32.5
33
33.5
34
34.5
35
35.5
36
36.5
37
37.5
38
38.5
39
1 2 3
Counseling Sessions
Scores
Compassionate Healertime (p = .04)
Competent Practitionertime (p = .01)
Qualitative Prompts
• In one word or phrase how would you describe the counseling session?
• Any additional comments about the session would be most appreciated.
• In one word or phrase how do you feel about the miscarriage now?
Ses
sio
n 3
Ses
sio
n 2
Ses
sio
n 1
2067 statements about nurse counseling
sessions
Content AnalysisContent Analysis
Failing to do for
Doing for
Being with
Knowing
Enabling
MaintainingBelief
5 caring & 1 non-caring
processes
uplifting
healing
ready tomove on
understand my mate
nurse understands
getting connected
comforting
skilled nurse
well run session
helpful
ineffective intervention
more needed
ineffective nurse
nurse compassion
open up feelings
informative
Inductive content analysis Deductive comparison
54 codes
16 categories
• Knowinggetting connected
understand my mate
Nurse is understanding
• Being withcompassionate nurse
opened up feelings
• Doing forwell run session
competent nurse
comforting
• Enablinginformative
helpful
• Failing do-formore needed
ineffective intervention
ineffective nurse
• Maintaining beliefhealing
uplifting
ready to move on
5 Caring and 1 non-Caring Processes16 Categories
How many individuals made at least one statement indicating the counseling was caring?
Session1 Session2 Session3 N % N % N % WOMEN Caring 161 95.3 78 92.9 74 88.1 Failure to do for 1 0.6 1 1.1 4 4.8 Blank 7 4.1 5 6.0 6 7.1 Total 169 100.0 84 100.0 84 100.0 MEN Caring 152 89.9 68 81.0 65 77.3 Failure to do for 3 2.2 1 1.1 3 3.6 Blank 14 8.3 15 17.9 19 22.6 Total 169 100.0 84 100.0 84 100.0
What percent of women experienced What percent of women experienced each caring process?each caring process?
0
10
20
30
40
50
60
70
Percent
Session 1 Session 2 Session 3
Maintain belief
Knowing
Being With
Doing For
Enabling
Fail to Do For
What percent of men experienced What percent of men experienced each caring process?each caring process?
0
10
20
30
40
50
60
70
Percent
Session 1 Session 2 Session 3
Maintain belief
Knowing
Being With
Doing For
Enabling
Fail to Do For
How did couples feel after counseling?How did couples feel after counseling?
• Healing (at peace, wanting to move on, optimistic…)
• Sad (grieving, disappointed, wish it did not happen…)
• Disrupted (family disrupted, part of us is gone…)
• Adrift (feeling lost, ambivalent, numb inside…)
• Resentful (remorseful, angry at God, annoyed…)
• Raw (painful burden, hovers in my life, helpless…)
Feelings Right after Counseling
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
complicated 23.1 22.7 14.7
sad 41.3 24.5 21.1
healing 35.5 52.7 64.2
1 2 30%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
complicated 13.3 10.7 6.2
sad 31.6 10.7 14.8
healing 55.1 78.6 79
1 2 3
Women Men
64% 47% 36%
LOSS
45% 21% 21%
LOSS
Summary: Feelings about Miscarriage
• 35.5% of women indicated they were healing after session 1 and 64.2% after session 3.
• 55.1% of men indicated they were healing after
session 1 and 79% after session 3.
• Since these analyses are only descriptive, we do not know if these increases are attributable to the healing effects of time or to our counseling sessions.
Qualitative Caring Summary
• In all three sessions the most commonly endorsed caring categories were Doing For, Enabling and Maintaining Belief.
• The majority of “failing to do for” statements focused on couples’ desires for more time, sessions, or support.
Quantitative Caring Summary
• Both nurses were rated as highly caring, compassionate, competent, and empathetic, with both partners rating nurses similarly.
• The highest competence, compassion, and caring ratings were at Session 2 possibly due to the nurse-couple relationship deepening, the content being more relevant, couples needing more caring, or the nurse being more responsive.
Conclusion
Caring was delivered as intended
Limitations
• These analyses are merely evaluative of the nurse counseling intervention and do not tell us anything about treatment outcomes.
Treatment Outcomes
Is there a difference in rate of resolution of grief and depression based on gender or treatment condition?
Two QuestionsTwo Questions:
Measures
Depression: CES-D (Radloff, 1977 )
Grief: Miscarriage Grief Inventory (Nikcevic et al, 1999)
Pure Grief Grief-Related Emotions Adjustment
Chronbach alphas ranged from .759 to .938
Analysis: Multi-level Modeling
Assumptions
1. Since all participants exist in the context of a couple relationship, each individual’s recovery is impacted by their partner’s recovery.
2. Since women and men were treated together, each couple’s recovery is impacted by their treatment condition.
3. Hence, the slope of each person’s recovery line is estimated based on their own scores over time, as influenced by their partner’s scores over time, as influenced by their assigned treatment condition
Treatment
Couple
Individual
Results
Bayesian Odds Ratios
BO = Bayesian Odds RatioP = Probability that slope is steeper than control
Evidence in Favor of Ho that Tx > control
RED INK = Substantial
BLUE INK = Strong (Kass and Raftery, 1995)
Treatments vs Controlcontrolling for time since loss
andhistory of treatment for depression, anxiety, or grief
Self Caring Combined Caring Nurse Caring Female Male Female Male Female Male
BO P BO P BO P BO P BO P BO P
Pure Grief 7.1 .88 1.0 .50 3.1 .76 23.3 .96 5.3 .84 17.4 .95
Grf Rel Emots 3.5 .78 .29 .22 .54 .35 5.1 .84 2.6 .72 2.4 .70
Adjustment 2.6 .72 4.5 .82 1.5 .60 3.3 .77 3.0 .75 2.8 .74
Total Grief 5.4 .84 .92 .48 1.6 .61 11.5 .92 4.8 .83 8.3 .89
Depression 2.2 .69 .31 .24 1.5 .6 .21 .18 7.4 .88 1.3 .56
Thank you